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Server IP : 128.199.20.84 / Your IP : 108.162.216.72 Web Server : Apache/2.4.41 (Ubuntu) System : Linux competent-maruti 5.4.0-128-generic #144-Ubuntu SMP Tue Sep 20 11:00:04 UTC 2022 x86_64 User : www-data ( 33) PHP Version : 8.0.20 Disable Function : pcntl_alarm,pcntl_fork,pcntl_waitpid,pcntl_wait,pcntl_wifexited,pcntl_wifstopped,pcntl_wifsignaled,pcntl_wifcontinued,pcntl_wexitstatus,pcntl_wtermsig,pcntl_wstopsig,pcntl_signal,pcntl_signal_get_handler,pcntl_signal_dispatch,pcntl_get_last_error,pcntl_strerror,pcntl_sigprocmask,pcntl_sigwaitinfo,pcntl_sigtimedwait,pcntl_exec,pcntl_getpriority,pcntl_setpriority,pcntl_async_signals,pcntl_unshare, MySQL : OFF | cURL : ON | WGET : ON | Perl : ON | Python : OFF Directory (0775) : /var/www/html/application/views/ |
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<div class="insurance-banner" style="background-image: url(<?php echo base_url();?>assets/images/insurance-banner.jpg)">
<div class="container">
<div class="row">
<div class="col-12">
<div class="banner-title-card">
<!-- <h5>protect your finances with</h5>-->
<h4 style="color: #000 !important;">Škoda Insurance Advantage</h4>
</div>
</div>
</div>
</div>
</div>
<section class="insurance-form">
<div class="container">
<div id='crmWebToEntityForm' class='zcwf_lblLeft crmWebToEntityForm'>
<meta name='viewport' content='width=device-width, initial-scale=1.0'>
<META HTTP-EQUIV='content-type' CONTENT='text/html;charset=UTF-8'>
<form action='<?php echo base_url();?>save-insurance' method='POST' enctype='multipart/form-data' accept-charset='UTF-8'>
<!-- Do not remove this code. -->
<div class="form-row">
<div class="col-12">
<h3>My Car Details :</h3>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='LEADCF6'>Model<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><select class='zcwf_col_fld_slt custom-select mr-sm-2' id='LEADCF6' name='model' required>
<option value=''>-Select Model-</option>
<option value='SKODA OCTAVIA'>ŠKODA OCTAVIA</option>
<option value='SKODA KUSHAQ'>ŠKODA KUSHAQ</option>
<option value='SKODA RAPID'>ŠKODA RAPID</option>
<option value='SKODA SUPERB'>ŠKODA SUPERB</option>
</select>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='LEADCF1'>Registration Number<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><input type='text' id='registration_number' name='registration_number' class="form-control" maxlength='255' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group date">
<div class="has-float-label">
<label for="name">Registration Year</label>
<input type="date" ng-model="vars.startDate" id='registration_year' name='registration_year' class="form-control" required>
</div>
</div>
</div>
<div class="col-md-6 mb-3">
<div class="input-group">
<div class="input-group-prepend">
<span class="input-group-text" id="inputGroupFileAddon01">Vehicle RC</span>
</div>
<div class="custom-file">
<input type="file" class="custom-file-input" name='vehicle_rc_file' aria-describedby="inputGroupFileAddon01" required />
<label class="custom-file-label" for="customFile">Choose file</label>
</div>
</div>
</div>
<div class="col-md-6 mb-3">
<div class="input-group">
<div class="input-group-prepend">
<div class='zcwf_col_lab input-group-text'>Vehicle Insurance</div>
</div>
<div class="custom-file">
<input type="file" class="custom-file-input" name='vehicle_insurance_file' aria-describedby="inputGroupFileAddon01" required />
<label class="custom-file-label" for="customFile">Choose file</label>
</div>
</div>
</div>
</div>
<div class="form-row">
<div class="col-12">
<h3>Existing Policy :</h3>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="last-name">Policy Number</label>
<input type="text" name="policy_number" class="form-control" required>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Company'>Insurance Company</label>
</div>
<div class='zcwf_col_fld'><input type='text' id='insurance_company' name='insurance_company' class="form-control" maxlength='100' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group date">
<div class="has-float-label">
<label for="last-name">Insurance Expiry Date</label>
<input type="date" ng-model="vars.startDate" name="insurance_expiry_date" class="form-control" required>
</div>
</div>
</div>
</div>
<div class="form-row">
<div class="col-12">
<h3>My Contact Details :</h3>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Last_Name'>Name<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><input type='text' id='firstname' name='firstname' class="form-control" maxlength='80' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Email'>Email</label>
</div>
<div class='zcwf_col_fld'>
<input type='email' ftype='email' id='Email' name='email' class="form-control" maxlength='100'>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Phone'>Phone<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><input type='tel' id='phone' class="form-control" name='phone' maxlength='10' minlength='10' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">Select Claim</label>
<select class="custom-select mr-sm-2" id='claim' name='claim' required>
<option value="">Select Claim</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
<div style='display:none;' id='ncp'>ncp<br/>
<br/>
<input type='text' class='text' name='ncp' value size='20' />
<br/>
</div>
</div>
</div>
</div>
<div class="col-md-12 mb-3">
<div class="form-group">
<p>Disclaimer: I agree that by clicking the ‘Submit’ button below, I am explicitly soliciting a call / Message from Ring Road Škoda (Masyy Cars Private Limited) or its Representatives on my ‘Mobile’.</p>
<div class="form-check mb-5">
<input class="form-check-input" type="checkbox" value="" id="invalidCheck" required>
<label class="form-check-label" for="invalidCheck">
Please agree with the above disclaimer
</label>
</div>
</div>
<input type="hidden" id="zc_gad" name="zc_gad" value="" />
<button class="btn btn-primary formsubmit zcwf_button" id='formsubmit' name="submit" type="submit">Get Your Insurance Now </button>
</div>
</div>
</form>
</META>
</div>
</div>
</section>